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Nambiar M, Bee YM, Chan YE, Ho Mien I, Guretno F, Carmody D, Lee PC, Chia SY, Salim NNM, Krishnaswamy P. A drug mix and dose decision algorithm for individualized type 2 diabetes management. NPJ Digit Med 2024; 7:254. [PMID: 39289474 DOI: 10.1038/s41746-024-01230-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 08/19/2024] [Indexed: 09/19/2024] Open
Abstract
Pharmacotherapy guidelines for type 2 diabetes (T2D) emphasize patient-centered care, but applying this approach effectively in outpatient practice remains challenging. Data-driven treatment optimization approaches could enhance individualized T2D management, but current approaches cannot account for drug-specific and dose-dependent variations in safety and efficacy. We developed and evaluated an AI Drug mix and dose Advisor (AIDA) for glycemic management, using electronic medical records from 107,854 T2D patients in the SingHealth Diabetes Registry. Given a patient's medical profile, AIDA leverages a predict-then-optimize approach to identify the minimal drug mix and dose changes required to optimize glycemic control, subject to clinical knowledge-based guidelines. On unseen data from large internal, external, and temporal validation sets, AIDA recommendations were estimated to improve post-visit glycated hemoglobin (HbA1c) by an average of 0.40-0.68% over standard of care (P < 0.0001). In qualitative evaluations on 60 diverse cases by a panel of three endocrinologists, AIDA recommendations were mostly rated as reasonable and precise. Finally, AIDA's ability to account for drug-dose specifics offered several advantages over competing methods, including greater consistency with practice preferences and clinical guidelines for practical but effective options, indication-based treatments, and renal dosing. As AIDA provides drug-dose recommendations to improve outcomes for individual T2D patients, it could be used for clinical decision support at point-of-care, especially in resource-limited settings.
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Grants
- H19/01/a0/023 - Diabetes Clinic of the Future Agency for Science, Technology and Research (A*STAR)
- H19/01/a0/023 - Diabetes Clinic of the Future Agency for Science, Technology and Research (A*STAR)
- H19/01/a0/023 - Diabetes Clinic of the Future Agency for Science, Technology and Research (A*STAR)
- H19/01/a0/023 - Diabetes Clinic of the Future Agency for Science, Technology and Research (A*STAR)
- H19/01/a0/023 - Diabetes Clinic of the Future Agency for Science, Technology and Research (A*STAR)
- H19/01/a0/023 - Diabetes Clinic of the Future Agency for Science, Technology and Research (A*STAR)
- H19/01/a0/023 - Diabetes Clinic of the Future Agency for Science, Technology and Research (A*STAR)
- H19/01/a0/023 - Diabetes Clinic of the Future Agency for Science, Technology and Research (A*STAR)
- H19/01/a0/023 - Diabetes Clinic of the Future Agency for Science, Technology and Research (A*STAR)
- H19/01/a0/023 - Diabetes Clinic of the Future Agency for Science, Technology and Research (A*STAR)
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Affiliation(s)
- Mila Nambiar
- Institute for Infocomm Research, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Yong Mong Bee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
| | - Yu En Chan
- Institute for Infocomm Research, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Ivan Ho Mien
- Institute for Infocomm Research, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Feri Guretno
- Institute for Infocomm Research, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - David Carmody
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Phong Ching Lee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Sing Yi Chia
- Health Services Research Unit, Singapore General Hospital, Singapore, Singapore
| | | | - Pavitra Krishnaswamy
- Institute for Infocomm Research, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore.
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Radkowski P, Krupiniewicz KJ, Suchcicki M, Machoń NJ, Cappello S, Szewczyk M, Wolska JM, Stompór T. Navigating Anesthesia: Muscle Relaxants and Reversal Agents in Patients with Renal Impairment. Med Sci Monit 2024; 30:e945141. [PMID: 39188037 PMCID: PMC11365435 DOI: 10.12659/msm.945141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 06/14/2024] [Indexed: 08/28/2024] Open
Abstract
This comprehensive review explores the interaction between neuromuscular blocking agents, reversal agents, and renal function, focusing on various drugs commonly used in anesthesia and their effects on kidney health. Succinylcholine, commonly used for anesthesia induction, can trigger elevated potassium levels in patients with specific medical conditions, leading to serious cardiac complications. While studies suggest the use of succinylcholine in patients with renal failure is safe, cases of postoperative hyperkalemia warrant further investigation. Some agents, such as atracurium and mivacurium, are minimally affected by impaired kidney function, whereas others, such as cisatracurium and rocuronium, can have altered clearance, necessitating dose adjustments in patients with renal failure. The reversal agents neostigmine and sugammadex affect renal markers, while cystatin C levels remain relatively stable with sugammadex use, indicating its milder impact on glomerular function, compared with neostigmine. Notably, the combination of rocuronium and sugammadex in rat studies shows potential nephrotoxic effects, cautioning against the simultaneous use of these agents. In conclusion, understanding the interplay between neuromuscular blocking agents and renal function is crucial for optimizing patient care during anesthesia. While some agents can be used safely in patients with renal failure, others can require careful dosing and monitoring. Further research is needed to comprehensively assess the long-term impact of these agents on kidney health, especially in high-risk patient populations. This article aims to review the use of muscle relaxants and reversal for anesthesia in patients with impaired renal function.
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Affiliation(s)
- Paweł Radkowski
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
- Department of Anesthesiology and Intensive Care, Regional Specialist Hospital, Olsztyn, Poland
- Department of Anesthesiology and Intensive Care, Hospital zum Heiligen Geist in Fritzlar, Fritzlar, Germany
| | | | - Mariusz Suchcicki
- Faculty of Medicine, Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Natalia Joanna Machoń
- Faculty of Medicine, Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Sara Cappello
- Faculty of Medicine and Surgery, University of Cagliari, Cagliari, Italy
| | - Maciej Szewczyk
- Residency in Rheumatology, University Clinical Hospital No. 1 in Szczecin, Szczecin, Poland
| | - Joanna Maria Wolska
- Department of Anesthesiology and Intensive Care, Regional Specialist Hospital, Olsztyn, Poland
| | - Tomasz Stompór
- Department of Nephrology, Transplantology and Internal Diseases, Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
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Ghosh A, Ninave S. Anesthesia Management in Antenatal Care for Women With Chronic Kidney Disease: A Comprehensive Review. Cureus 2024; 16:e66389. [PMID: 39246885 PMCID: PMC11379099 DOI: 10.7759/cureus.66389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 08/07/2024] [Indexed: 09/10/2024] Open
Abstract
Chronic kidney disease (CKD) presents significant challenges in the management of pregnant women due to its impact on renal function and cardiovascular stability. This review examines the crucial role of anesthesia management in antenatal care for women with CKD, focusing on the complexities introduced by renal dysfunction and the implications for maternal and fetal health outcomes. The review discusses the physiological changes in CKD during pregnancy, highlighting the increased risks of hypertension, proteinuria, and adverse fetal outcomes. Anesthesia considerations, including the choice of anesthesia techniques (general anesthesia, regional anesthesia), perioperative monitoring, and management of fluid and electrolyte balance, are analyzed in the context of CKD-specific challenges. Clinical outcomes and current evidence regarding anesthesia efficacy and safety in CKD patients are reviewed, emphasizing the need for tailored anesthesia protocols to ensure optimal maternal comfort and fetal safety. The review concludes by identifying research gaps and proposing future directions to enhance anesthesia practices and improve outcomes for pregnant women with CKD undergoing surgical interventions or labor management.
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Affiliation(s)
- Angan Ghosh
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sanjot Ninave
- Anesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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4
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Liabeuf S, Hafez G, Pešić V, Spasovski G, Bobot M, Mačiulaitis R, Bumblyte IA, Ferreira AC, Farinha A, Malyszko J, Pépin M, Massy ZA, Unwin R, Capasso G, Mani LY. Drugs with a negative impact on cognitive functions (part 3): antibacterial agents in patients with chronic kidney disease. Clin Kidney J 2024; 17:sfae174. [PMID: 39114495 PMCID: PMC11304602 DOI: 10.1093/ckj/sfae174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Indexed: 08/10/2024] Open
Abstract
The relationship between chronic kidney disease (CKD) and cognitive function has received increased attention in recent years. Antibacterial agents (ABs) represent a critical component of therapy regimens in patients with CKD due to increased susceptibility to infections. Following our reviewing work on the neurocognitive impact of long-term medications in patients with CKD, we propose to focus on AB-induced direct and indirect consequences on cognitive function. Patients with CKD are predisposed to adverse drug reactions (ADRs) due to altered drug pharmacokinetics, glomerular filtration decline, and the potential disruption of the blood-brain barrier. ABs have been identified as a major cause of ADRs in vulnerable patient populations. This review examines the direct neurotoxic effects of AB classes (e.g. beta-lactams, fluoroquinolones, aminoglycosides, and metronidazole) on the central nervous system (CNS) in patients with CKD. We will mainly focus on the acute effects on the CNS associated with AB since they are the most extensively studied effects in CKD patients. Moreover, the review describes the modulation of the gut microbiota by ABs, potentially influencing CNS symptoms. The intricate brain-gut-kidney axis emerges as a pivotal focus, revealing the interplay between microbiota alterations induced by ABs and CNS manifestations in patients with CKD. The prevalence of antibiotic-associated encephalopathy in patients with CKD undergoing intravenous AB therapy supports the use of therapeutic drug monitoring for ABs to reduce the number and seriousness of ADRs in this patient population. In conclusion, elucidating AB-induced cognitive effects in patients with CKD demands a comprehensive understanding and tailored therapeutic strategies that account for altered pharmacokinetics and the brain-gut-kidney axis.
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Affiliation(s)
- Sophie Liabeuf
- Pharmacoepidemiology Unit, Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France
| | - Gaye Hafez
- Department of Pharmacology, Faculty of Pharmacy, Altinbas University, Istanbul, Turkey
| | - Vesna Pešić
- Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Goce Spasovski
- Department of Nephrology, Clinical Centre “Mother Theresa”, Saints Cyril and Methodius University, Skopje, North Macedonia
| | - Mickaël Bobot
- Aix-Marseille University, Department of Nephrology, AP-HM, La Conception Hospital, Marseille, France; C2VN Laboratory, Inserm 1263, INRAE 1260, Aix-Marseille University, Marseille, France
| | - Romaldas Mačiulaitis
- Department of Nephrology, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Institute of Physiology and Pharmacology, Faculty of Medicines, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Inga Arune Bumblyte
- Department of Nephrology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ana Carina Ferreira
- Nephrology Department, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
- Universidade Nova de Lisboa-Faculdade de Ciências Médicas-Nephology, Lisbon, Portugal
| | - Ana Farinha
- Department of Nephrology, Hospital de Vila Franca de Xira, Lisbon, Portugal
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Marion Pépin
- Department of Geriatrics, Ambroise Paré University Medical Center, APHP, Boulogne-Billancourt, France
- Paris-Saclay University, UVSQ, Inserm, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Villejuif, France
| | - Ziad A Massy
- Paris-Saclay University, UVSQ, Inserm, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Villejuif, France
- Department of Nephrology, Ambroise Paré University Medical Center, APHP, Paris, France
| | - Robert Unwin
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Giovambattista Capasso
- Department of Translantional Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
- Biogem Research Institute, Ariano Irpino, Italy
| | - Laila-Yasmin Mani
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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5
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Jeong SI, Ban MS, Hwang JG, Park MK, Lim S, Kim S, Kwon SK, Kim Y, Cho JM, Na JJ, Huh W, Chung JY. The effect of renal function on the pharmacokinetics and pharmacodynamics of enavogliflozin, a potent and selective sodium-glucose cotransporter-2 inhibitor, in type 2 diabetes. Diabetes Obes Metab 2024; 26:2588-2597. [PMID: 38618974 DOI: 10.1111/dom.15573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 04/16/2024]
Abstract
AIMS To explore the effect of renal function on the pharmacokinetic (PK) and pharmacodynamic (PD) profile and safety of enavogliflozin, a selective sodium-glucose cotransporter 2 (SGLT2) inhibitor, in patients with type 2 diabetes mellitus (T2DM). METHODS An open-label, two-part clinical trial was conducted in T2DM patients, stratified by renal function: Group 1, normal renal function; Group 2, mild renal impairment (RI); Group 3, moderate RI; and Group 4, severe RI. In Part A, Groups 2 and 4 received enavogliflozin 0.5 mg once. In Part B, Groups 1 and 3 received enavogliflozin 0.5 mg once daily for 7 days. Serial blood and timed urine samples were collected to analyse the PK and PD characteristics of enavogliflozin. Pearson's correlation coefficients were calculated to assess the correlations between PK or PD parameters and creatinine clearance (CrCL). RESULTS A total of 21 patients completed the study as planned. The area under the curve (AUC) for enavogliflozin was not significantly correlated with CrCL, although the maximum concentration slightly decreased as renal function decreased. By contrast, daily urinary glucose excretion (UGE) was positively correlated with CrCL after both single- (r = 0.7866, p < 0.0001) and multiple-dose administration (r = 0.6606, p = 0.0438). CONCLUSIONS Systemic exposure to oral enavogliflozin 0.5 mg was similar among the patients with T2DM regardless of their renal function levels. However, the glucosuric effect of enavogliflozin decreased with RI. Considering the UGE observed and approved therapeutic use of other SGLT2 inhibitors, the efficacy of enavogliflozin with regard to glycaemic control could be explored in patients with mild and moderate RI (estimated glomerular filtration rate ≥30 or ≥45 mL/min/1.73 m2) in a subsequent larger study.
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Affiliation(s)
- Sae Im Jeong
- Department of Clinical Pharmacology and Therapeutics, Chungbuk National University College of Medicine and Hospital, Cheongju-si, Republic of Korea
| | - Mu Seong Ban
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Bundang Hospital, Seongnam, Republic of Korea
| | - Jun-Gi Hwang
- Department of Clinical Pharmacology and Therapeutics, Chungbuk National University College of Medicine and Hospital, Cheongju-si, Republic of Korea
| | - Min-Kyu Park
- Department of Clinical Pharmacology and Therapeutics, Chungbuk National University College of Medicine and Hospital, Cheongju-si, Republic of Korea
| | - Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Soon Kil Kwon
- Department of Internal Medicine, Chungbuk National University College of Medicine and Hospital, Cheongju-si, Republic of Korea
| | - Yoonjin Kim
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Bundang Hospital, Seongnam, Republic of Korea
| | - Jae Min Cho
- Clinical Development Center, Daewoong Pharmaceutical Co., Ltd., Seoul, Republic of Korea
| | - Jae Jin Na
- Clinical Development Center, Daewoong Pharmaceutical Co., Ltd., Seoul, Republic of Korea
| | - Wan Huh
- Clinical Development Center, Daewoong Pharmaceutical Co., Ltd., Seoul, Republic of Korea
| | - Jae-Yong Chung
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Bundang Hospital, Seongnam, Republic of Korea
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6
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Hulin A, Gelé T, Fenioux C, Kempf E, Sahali D, Tournigand C, Ollero M. Pharmacology of Tyrosine Kinase Inhibitors: Implications for Patients with Kidney Diseases. Clin J Am Soc Nephrol 2024; 19:927-938. [PMID: 38079278 PMCID: PMC11254026 DOI: 10.2215/cjn.0000000000000395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Tyrosine kinase inhibitors (TKI) have introduced a significant advancement in cancer management. These compounds are administered orally, and their absorption holds a pivotal role in determining their variable efficacy. They exhibit extensive distribution within the body, binding strongly to both plasma and tissue proteins. Often reliant on efflux and influx transporters, TKI undergo primary metabolism by intestinal and hepatic cytochrome P450 enzymes, with nonkidney clearance being predominant. Owing to their limited therapeutic window, many TKI display considerable intraindividual and interindividual variability. This review offers a comprehensive analysis of the clinical pharmacokinetics of TKI, detailing their interactions with drug transporters and metabolic enzymes, while discussing potential clinical implications. The prevalence of kidney conditions, such as AKI and CKD, among patients with cancer is explored in their effect on TKI pharmacokinetics. Finally, the potential nephrotoxicity associated with TKI is also examined.
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Affiliation(s)
- Anne Hulin
- Pharmacology Laboratory, University Medicine Department of Biology-Pathology, AP-HP, GH Henri Mondor, University Paris-Est Creteil, Créteil, France
- University Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France
| | - Thibaut Gelé
- Pharmacology Laboratory, University Medicine Department of Biology-Pathology, AP-HP, GH Henri Mondor, University Paris-Est Creteil, Créteil, France
- University Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France
| | - Charlotte Fenioux
- Oncology Unit, University Medicine Department of Cancer, AP-HP, GH Henri Mondor, University Paris-Est Creteil, Créteil, France
| | - Emmanuelle Kempf
- University Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France
- Oncology Unit, University Medicine Department of Cancer, AP-HP, GH Henri Mondor, University Paris-Est Creteil, Créteil, France
| | - Dil Sahali
- University Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France
- Nephrology Unit, University Medicine Department of Medicine, AP-HP, GH Henri Mondor, University Paris-Est Creteil, Créteil, France
| | - Christophe Tournigand
- University Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France
- Oncology Unit, University Medicine Department of Cancer, AP-HP, GH Henri Mondor, University Paris-Est Creteil, Créteil, France
| | - Mario Ollero
- University Paris Est Creteil, INSERM, IMRB, F-94010 Creteil, France
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7
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Hall RK, Kazancıoğlu R, Thanachayanont T, Wong G, Sabanayagam D, Battistella M, Ahmed SB, Inker LA, Barreto EF, Fu EL, Clase CM, Carrero JJ. Drug stewardship in chronic kidney disease to achieve effective and safe medication use. Nat Rev Nephrol 2024; 20:386-401. [PMID: 38491222 DOI: 10.1038/s41581-024-00823-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 03/18/2024]
Abstract
People living with chronic kidney disease (CKD) often experience multimorbidity and require polypharmacy. Kidney dysfunction can also alter the pharmacokinetics and pharmacodynamics of medications, which can modify their risks and benefits; the extent of these changes is not well understood for all situations or medications. The principle of drug stewardship is aimed at maximizing medication safety and effectiveness in a population of patients through a variety of processes including medication reconciliation, medication selection, dose adjustment, monitoring for effectiveness and safety, and discontinuation (deprescribing) when no longer necessary. This Review is aimed at serving as a resource for achieving optimal drug stewardship for patients with CKD. We describe special considerations for medication use during pregnancy and lactation, during acute illness and in patients with cancer, as well as guidance for the responsible use of over-the-counter drugs, herbal remedies, supplements and sick-day rules. We also highlight inequities in medication access worldwide and suggest policies to improve access to quality and essential medications for all persons with CKD. Further strategies to promote drug stewardship include patient education and engagement, the use of digital health tools, shared decision-making and collaboration within interdisciplinary teams. Throughout, we position the person with CKD at the centre of all drug stewardship efforts.
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Affiliation(s)
- Rasheeda K Hall
- Division of Nephrology, Department of Medicine, and Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | | | | | - Sofia B Ahmed
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lesley A Inker
- Division of Nephrology, Department of Internal Medicine, Tufts Medical Center, Boston, MA, USA
| | | | - Edouard L Fu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Ontario, Canada
| | - Juan J Carrero
- Medical Epidemiology and Biostatistics, Karolinska Institutet, and Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden.
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8
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Haahr H, Cieslarová B, Hingst JR, Jiang S, Kristensen NR, Kupčová V, Nørgreen L, Wagner FDH, Ignatenko S. The Effect of Various Degrees of Renal or Hepatic Impairment on the Pharmacokinetic Properties of Once-Weekly Insulin Icodec. Clin Pharmacokinet 2024; 63:819-830. [PMID: 38722461 PMCID: PMC11222188 DOI: 10.1007/s40262-024-01375-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND AND OBJECTIVE Icodec is a once-weekly insulin being developed to provide basal insulin coverage in diabetes mellitus. This study evaluated the effects of renal or hepatic impairment on icodec pharmacokinetics. METHODS Two open-label, parallel-group, single-dose (1.5 U/kg subcutaneously) trials were conducted. In a renal impairment trial, 58 individuals were allocated to normal renal function (measured glomerular filtration rate ≥ 90 mL/min), mild (60 to < 90 mL/min), moderate (30 to < 60 mL/min) or severe (< 30 mL/min) renal impairment or end-stage renal disease. In a hepatic impairment trial, 25 individuals were allocated to normal hepatic function or mild (Child-Pugh Classification grade A), moderate (grade B) or severe (grade C) hepatic impairment. Blood was sampled frequently for a pharmacokinetic analysis until 35 days post-dose. RESULTS The shape of the icodec pharmacokinetic profile was not affected by renal or hepatic impairment. Total icodec exposure was greater for mild (estimated ratio [95% confidence interval]: 1.12 [1.01; 1.24]), moderate (1.24 [1.12; 1.37]) and severe (1.28 [1.16; 1.42]) renal impairment, and for end-stage renal disease (1.14 [1.03; 1.28]), compared with normal renal function. It was also greater for mild (1.13 [1.00; 1.28]) and moderate (1.15 [1.02; 1.29]) hepatic impairment versus normal hepatic function. There was no statistically significant difference between severe hepatic impairment and normal hepatic function. Serum albumin levels (range 2.7-5.1 g/dL) did not statistically significantly influence icodec exposure. CONCLUSIONS The clinical relevance of the slightly higher icodec exposure with renal or hepatic impairment is limited as icodec should be dosed according to individual need. No specific icodec dose adjustment is required in renal or hepatic impairment. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifiers: NCT03723785 and NCT04597697.
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Affiliation(s)
| | | | | | | | | | - Viera Kupčová
- Dérer's Hospital, Comenius University, Bratislava, Slovakia
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9
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Stevens PE, Ahmed SB, Carrero JJ, Foster B, Francis A, Hall RK, Herrington WG, Hill G, Inker LA, Kazancıoğlu R, Lamb E, Lin P, Madero M, McIntyre N, Morrow K, Roberts G, Sabanayagam D, Schaeffner E, Shlipak M, Shroff R, Tangri N, Thanachayanont T, Ulasi I, Wong G, Yang CW, Zhang L, Levin A. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int 2024; 105:S117-S314. [PMID: 38490803 DOI: 10.1016/j.kint.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 03/17/2024]
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10
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Džidić-Krivić A, Sher EK, Kusturica J, Farhat EK, Nawaz A, Sher F. Unveiling drug induced nephrotoxicity using novel biomarkers and cutting-edge preventive strategies. Chem Biol Interact 2024; 388:110838. [PMID: 38104745 DOI: 10.1016/j.cbi.2023.110838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/03/2023] [Accepted: 12/15/2023] [Indexed: 12/19/2023]
Abstract
Drug-induced nephrotoxicity is still a significant obstacle in pharmacotherapy of various diseases and it accounts for around 25 % of serious side-effects reported after drug administration. Furthermore, some groups of drugs such as nonsteroidal anti-inflammatory drugs, antibiotics, antiviral drugs, antifungal drugs, immunosuppressants, and chemotherapeutic drugs have the "preference" for damaging the kidney and are often referred to as the kidney's "silent killer". Clinically, the onset of acute kidney injury associated with drug administration is registered in approximately 20 % of patients and many of them develop chronic kidney disease vulnerability. However, current knowledge about the mechanisms underlying this dangerous phenomenon is still insufficient with many unknowns. Hence, the valuable use of these drugs in clinical practice is significantly limited. The main aim of this study is to draw attention to commonly prescribed nephrotoxic drugs by clinicians or drugs bought over the counter. In addition, the complex relationship between immunological, vascular and inflammatory events that promote kidney damage is discussed. The practical use of this knowledge could be implemented in the engineering of novel biomarkers for early detection of drug-associated kidney damage such as Kidney Injury Molecule (KIM-1), lipocalin associated with neutrophil gelatinase (NGAL) and various microRNAs. In addition, the utilization of artificial intelligence (AI) for the development of computer algorithms that could detect kidney damage at an early stage should be further explored. Therefore, this comprehensive review provides a new outlook on drug nephrotoxicity that opens the door for further clinical research of novel potential drugs or natural products for the prevention of drug-induced nephrotoxicity and accessible education.
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Affiliation(s)
- Amina Džidić-Krivić
- Department of Neurology, Cantonal Hospital Zenica, Zenica, 72000, Bosnia and Herzegovina; International Society of Engineering Science and Technology, Nottingham, United Kingdom
| | - Emina K Sher
- Department of Biosciences, School of Science and Technology, Nottingham Trent University, Nottingham, NG11 8NS, United Kingdom.
| | - Jasna Kusturica
- Faculty of Medicine,Univerisity of Sarajevo, Sarajevo, 71000, Bosnia and Herzegovina
| | - Esma K Farhat
- International Society of Engineering Science and Technology, Nottingham, United Kingdom; Department of Food and Nutrition Research, Faculty of Food Technology, Juraj Strossmayer University of Osijek, Osijek, 31000, Croatia
| | - Asma Nawaz
- International Society of Engineering Science and Technology, Nottingham, United Kingdom; Department of Biochemistry, University of Agriculture, Faisalabad, 38040, Pakistan
| | - Farooq Sher
- Department of Engineering, School of Science and Technology, Nottingham Trent University, Nottingham, NG11 8NS, United Kingdom.
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11
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Giolando PA, Hopkins K, Davis BF, Vike N, Ahmadzadegan A, Ardekani AM, Vlachos PP, Rispoli JV, Solorio L, Kinzer-Ursem TL. Mechanistic Computational Modeling of Implantable, Bioresorbable Drug Release Systems. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2023; 35:e2301698. [PMID: 37243452 PMCID: PMC10697660 DOI: 10.1002/adma.202301698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/09/2023] [Indexed: 05/28/2023]
Abstract
Implantable, bioresorbable drug delivery systems offer an alternative to current drug administration techniques; allowing for patient-tailored drug dosage, while also increasing patient compliance. Mechanistic mathematical modeling allows for the acceleration of the design of the release systems, and for prediction of physical anomalies that are not intuitive and may otherwise elude discovery. This study investigates short-term drug release as a function of water-mediated polymer phase inversion into a solid depot within hours to days, as well as long-term hydrolysis-mediated degradation and erosion of the implant over the next few weeks. Finite difference methods are used to model spatial and temporal changes in polymer phase inversion, solidification, and hydrolysis. Modeling reveals the impact of non-uniform drug distribution, production and transport of H+ ions, and localized polymer degradation on the diffusion of water, drug, and hydrolyzed polymer byproducts. Compared to experimental data, the computational model accurately predicts the drug release during the solidification of implants over days and drug release profiles over weeks from microspheres and implants. This work offers new insight into the impact of various parameters on drug release profiles, and is a new tool to accelerate the design process for release systems to meet a patient specific clinical need.
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Affiliation(s)
- Patrick A Giolando
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
- School of Mechanical Engineering, Purdue University, West Lafayette, IN, 47907, USA
| | - Kelsey Hopkins
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
| | - Barrett F Davis
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
| | - Nicole Vike
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
| | - Adib Ahmadzadegan
- School of Mechanical Engineering, Purdue University, West Lafayette, IN, 47907, USA
| | - Arezoo M Ardekani
- School of Mechanical Engineering, Purdue University, West Lafayette, IN, 47907, USA
| | - Pavlos P Vlachos
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
- School of Mechanical Engineering, Purdue University, West Lafayette, IN, 47907, USA
| | - Joseph V Rispoli
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
| | - Luis Solorio
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
| | - Tamara L Kinzer-Ursem
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
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12
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Porter S. Prescribing medicines in people with renal impairment. Nurs Stand 2023; 38:69-74. [PMID: 37902020 DOI: 10.7748/ns.2023.e12218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 10/31/2023]
Abstract
Kidney disease is a common occurrence and alters how the body processes many drugs. Therefore, prescribers must consider the person's renal function before prescribing medicines and may need to amend the dose of renally excreted drugs. At present, there is limited data regarding dose adjustment in renal impairment, so prescribers require knowledge of pharmacokinetics. Prescribers also need to understand how the kidneys process drugs when functioning normally to be able to predict how renal impairment may affect pharmacokinetics. This article offers practical guidance on prescribing for adults who have stable chronic kidney disease and do not meet the criteria for specialist assessment. It also explores important steps that prescribers can take to optimise medicines use in this population.
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Affiliation(s)
- Sally Porter
- Department of Health Sciences, University of York, York, England
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13
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Molina P, Goicoechea M, Huarte E, Maduell F, Valero A, Martín-Malo A. Hemodiafiltration with endogenous reinfusion of the regenerated ultrafiltrate (HFR): towards a convective, diffusive, and adsorptive dialysis. Nefrologia 2023; 43:688-702. [PMID: 38176980 DOI: 10.1016/j.nefroe.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/28/2023] [Indexed: 01/06/2024] Open
Abstract
Hemodiafiltration with endogenous reinfusion of the ultrafiltrate (HFR) is a dialysis technique characterized by a resin cartridge with adsorptive properties that combines the mechanisms of diffusion, convection, and adsorption in a single therapeutic regimen. After nearly 20 years of clinical experience with HFR, this article reviews the accumulated evidence with this technique, considering whether adsorption reduction, as a third purification mechanism, should be the next step in the treatment of hemodialysis patients. HFR, beyond producing an extensive removal of uremic toxins, has demonstrated to reduce the loss of nutrients and other physiological components during the dialysis session as compared to online hemodiafiltration, ameliorating the inflammatory state and oxidative stress in this population. In addition to its ease of use, the technique is also highly biocompatible and can be used in patients with a compromised vascular access. Based on these observations, HFR appears to be an especially useful therapy for high-comorbidity patients, including those with frailty, malnutrition, or cardiovascular disease. In this review, we, as a consensus panel of nephrologists experienced with HFR, survey existing literature and summarize our views on when to use this technique, which patients may be best suited for HFR, and how to effectively prescribe and monitor this modality of dialysis in daily clinical practice.
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Affiliation(s)
- Pablo Molina
- Servicio de Nefrología, Hospital Universitari Dr. Peset, Universitat de València, FISABIO, Valencia, Spain.
| | - Marian Goicoechea
- Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Emma Huarte
- Servicio de Nefrología, Hospital de San Pedro, Logroño, Spain
| | - Francisco Maduell
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, Spain
| | - Alejandro Valero
- Servicio de Nefrología, Hospital Universitari Dr. Peset, Universitat de València, FISABIO, Valencia, Spain
| | - Alejandro Martín-Malo
- Servicio de Nefrología, Hospital Universitario Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Red Nacional de Investigación en Nefrología (REDinREN), Instituto de Salud Carlos III, Spain
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14
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Tanaka T, Kobuchi S, Ito Y, Sakaeda T. Pharmacokinetic evaluation of oxaliplatin combined with S-1 (SOX) chemotherapy in a rat model of colorectal cancer with acute kidney injury: predictive renal biomarkers for dose optimisation. Xenobiotica 2023; 53:613-620. [PMID: 37966716 DOI: 10.1080/00498254.2023.2283736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/11/2023] [Indexed: 11/16/2023]
Abstract
Dose adjustment based on renal function is essential in S-1, which contains the 5‑fluorouracil prodrug tegafur, and platinum-based agent oxaliplatin (SOX) combination chemotherapy for colorectal cancer in patients with chronic kidney disease. However, limited evidence on dose adjustment in acute kidney injury (AKI) and challenges in determining dosing strategies. This study investigated the pharmacokinetics of SOX chemotherapy and renal biomarkers in rats.AKI was prepared by renal ischaemia-reperfusion injury in 1,2-dimethylhydrazine-induced colorectal cancer model rats. Serum creatinine (sCr) levels were determined as a renal biomarker. After administration of S-1 (2 mg/kg tegafur) and oxaliplatin (5 mg/kg), drug concentrations of tegafur, 5-FU, and platinum were measured in the plasma and tumours.No alterations in the area under the plasma concentration-time curve (AUC0-24h) values of 5-fluorouracil were observed between control and AKI model rats. The tumour concentrations of 5-fluorouracil in the mild and severe AKI groups were significantly lower than control group. The AUC0-24h for platinum increased with AKI severity. Notably, population pharmacokinetic analysis identified sCr as a covariate in platinum distribution after SOX chemotherapy.To optimise dose adjustment of SOX chemotherapy in patients with AKI, sCr may be a key factor in determining the appropriate dose.
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Affiliation(s)
- Takumi Tanaka
- Department of Pharmacokinetics, Kyoto Pharmaceutical University, Kyoto, Japan
| | - Shinji Kobuchi
- Department of Pharmacokinetics, Kyoto Pharmaceutical University, Kyoto, Japan
| | - Yukako Ito
- Department of Pharmacokinetics, Kyoto Pharmaceutical University, Kyoto, Japan
| | - Toshiyuki Sakaeda
- Department of Pharmacokinetics, Kyoto Pharmaceutical University, Kyoto, Japan
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15
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Behal ML, Flannery AH, Barreto EF. Medication Management in the Critically Ill Patient with Acute Kidney Injury. Clin J Am Soc Nephrol 2023; 18:1080-1088. [PMID: 36723347 PMCID: PMC10564345 DOI: 10.2215/cjn.0000000000000101] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 02/02/2023]
Abstract
ABSTRACT AKI occurs frequently in critically ill patients. Patients with AKI, including those who require KRT, experience multiple pharmacokinetic and pharmacodynamic perturbations that dynamically influence medication effectiveness and safety. Patients with AKI may experience both subtherapeutic drug concentrations, which lead to ineffective therapy, and supratherapeutic drug concentrations, which increase the risk for toxicity. In critically ill patients with AKI not requiring KRT, conventional GFR estimation equations, especially those based on serum creatinine, have several limitations that can limit the accuracy when used for medication dosing. Alternative methods to estimate kidney function may be informative, including use of measured urinary creatinine clearance, kinetic eGFR, and equations that integrate novel kidney biomarkers. For critically ill patients with AKI requiring KRT, physicochemical properties of the drug, the KRT prescription and circuit configuration, and patient-specific factors each contribute to medication clearance. Evidence-based guidance for medication dosing during AKI requiring KRT is often limited. A working knowledge of the basic tenets of drug elimination during KRT can provide a framework for how to approach decision making when the literature is lacking. Iterative re-evaluation of a patient's progress toward therapeutic goals with a medication must occur over the arc of critical illness, including and especially in the setting of dynamic kidney function.
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Affiliation(s)
- Michael L. Behal
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
| | - Alexander H. Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
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16
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Aprilliano B, Giuliano C, Paxton RA, Edwin SB. Risk of bleeding with factor Xa inhibitors versus unfractionated heparin in patients with acute kidney injury. Pharmacotherapy 2023; 43:129-135. [PMID: 36588500 DOI: 10.1002/phar.2759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/12/2022] [Accepted: 12/16/2022] [Indexed: 01/03/2023]
Abstract
STUDY OBJECTIVE To compare bleeding and thromboembolic events in patients receiving therapeutic doses of apixaban or rivaroxaban versus unfractionated heparin (UFH) in patients with acute kidney injury (AKI). DESIGN Single-center, retrospective, observational study. SETTING Ascension St. John Hospital in Detroit, Michigan. PATIENTS Hospitalized adult patients who received therapeutic doses of factor Xa inhibitors (n = 250) or UFH (n = 250) for at least 24 h in the setting of AKI. MEASUREMENTS AND MAIN RESULTS After adjusting for confounding factors, patients who received a factor Xa inhibitor experienced a lower risk of composite major and clinically relevant nonmajor bleeding (CRNMB) events compared with UFH (OR: 0.57, 95% CI: 0.34-0.94; p = 0.03). There was a significantly decreased risk of CRNMB events in the factor Xa inhibitor group (OR: 0.55, 95% CI: 0.33-0.91, p = 0.02); however, no significant differences in major bleeding or venous thromboembolism (VTE) were noted. CONCLUSIONS Our results suggest that it may be preferable to continue patients in AKI on factor Xa inhibitors versus transitioning to UFH due to the lower risk of bleeding events.
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Affiliation(s)
- Bianca Aprilliano
- Department of Pharmacy, Ascension St. John Hospital, Detroit, Michigan, USA
| | - Christopher Giuliano
- Department of Pharmacy, Ascension St. John Hospital, Detroit, Michigan, USA.,Department of Pharmacy, Wayne State University Eugene Applebaum Applebaum College of Pharmacy and Health Sciences, Detroit, Michigan, USA
| | | | - Stephanie B Edwin
- Department of Pharmacy, Ascension St. John Hospital, Detroit, Michigan, USA
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17
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Principles for the Prevention of Medication-Induced Nephrotoxicity. Crit Care Nurs Clin North Am 2022; 34:361-371. [DOI: 10.1016/j.cnc.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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18
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Wang X, Rao J, Tan Z, Xun T, Zhao J, Yang X. Inflammatory signaling on cytochrome P450-mediated drug metabolism in hepatocytes. Front Pharmacol 2022; 13:1043836. [PMID: 36353494 PMCID: PMC9637984 DOI: 10.3389/fphar.2022.1043836] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/11/2022] [Indexed: 12/11/2023] Open
Abstract
Cytochrome P450 (CYP450) enzymes are membrane-bound blood proteins that are vital to drug detoxification, cell metabolism, and homeostasis. CYP450s belonging to CYP families 1-3 are responsible for nearly 80% of oxidative metabolism and complete elimination of approximately 50% of all common clinical drugs in humans liver hepatocytes. CYP450s can affect the body's response to drugs by altering the reaction, safety, bioavailability, and toxicity. They can also regulate metabolic organs and the body's local action sites to produce drug resistance through altered drug metabolism. Genetic polymorphisms in the CYP gene alone do not explain ethnic and individual differences in drug efficacy in the context of complex diseases. The purpose of this review is to summarize the impact of new inflammatory-response signaling pathways on the activity and expression of CYP drug-metabolizing enzymes. Included is a summary of recent studies that have identified drugs with the potential to regulate drug-metabolizing enzyme activity. Our goal is to inspire the development of clinical drug treatment processes that consider the impact of the inflammatory environment on drug treatment, as well as provide research targets for those studying drug metabolism.
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Affiliation(s)
- Xiaokang Wang
- Department of Pharmacy, Shenzhen Longhua District Central Hospital, Shenzhen, China
- Department of Pharmacy, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Jiaoyu Rao
- Department of Pharmacy, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Zhiyi Tan
- Guangzhou Customs Technology Center, Guangzhou, China
| | - Tianrong Xun
- Department of Pharmacy, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Jingqian Zhao
- Department of Pharmacy, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Xixiao Yang
- Department of Pharmacy, Shenzhen Hospital, Southern Medical University, Shenzhen, China
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19
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Bioanalysis of INCB000928 in hemodialysate: prevention of nonspecific binding and validation of surrogate matrices. Bioanalysis 2022; 14:1257-1270. [PMID: 36416749 DOI: 10.4155/bio-2022-0188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aim: To develop and validate a bioanalytical method for the quantification of INCB000928 in hemodialysate. Materials & methods: Blank dialysate and phosphate-buffered saline were compared with hemodialysate for surrogate matrix selection. Direct addition of internal standard without analyte extraction and a high-performance LC-MS/MS were used for analysis. Results & conclusion: INCB000928 in hemodialysate exhibited strong nonspecific binding to polypropylene containers. In the presence of 10% isopropyl alcohol, the loss of INCB000928 was fully recovered, regardless of pre- or post-addition of the solvent. Blank dialysate and phosphate-buffered saline were determined to be appropriate surrogate matrices by using a three-way cross-comparison and were subsequently validated in the quantitative analysis of INCB000928 in hemodialysate.
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20
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Fu C, Pei Q, Liang W, Yang B, Li W, Liu J, Tan H, Guo C, Zhang H, Yang G. Population Pharmacokinetic Modelling for Nifedipine to Evaluate the Effect of Parathyroid Hormone on CYP3A in Patients with Chronic Kidney Disease. Drug Des Devel Ther 2022; 16:2261-2274. [PMID: 35860523 PMCID: PMC9289454 DOI: 10.2147/dddt.s362607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 06/30/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Parathyroid hormone (PTH) can induce the downregulation of CYP3A in chronic kidney disease (CKD). Nevertheless, the effect of PTH on CYP3A-mediated clearance pathways from a clinical perspective remains unclear. Methods This study employed population pharmacokinetic (PopPK) modeling to delineate potential changes in CYP3A activity in patients with CKD. Pharmacokinetic data for nifedipine, a typical CYP3A substrate, as well as covariate information, were prospectively collected from 157 patients with a total of 612 concentrations. PopPK data analysis was performed using a nonlinear mixed-effects model. Results The pharmacokinetics of nifedipine were optimally described according to a one-compartment model with zero-order absorption and first-order elimination. The estimated population parameters (and interindividual variability) were apparent clearance (CL/F) 49.61 L/h (58.33%) and apparent volume of distribution (V/F) 2300.26 L (45.62%), and the PTH level negatively correlated with CL/F. In comparison with the reference level, it was observed that the dosage of nifedipine should be reduced with the maximum boundary value of PTH, after a Monte Carlo simulation. Conclusion This study provides insight into the effects of PTH on CYP3A-mediated clearance pathways. Moreover, PTH could be used as a guide for the appropriate administration of CYP3A eliminated drugs in patients with CKD.
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Affiliation(s)
- Chengxiao Fu
- Center for Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- The First Affiliated Hospital, Department of Pharmacy, Hengyang Medical School, University of South China, Hengyang, People’s Republic of China
| | - Qi Pei
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Wu Liang
- Research Center of Drug Clinical Evaluation of Central South University, Changsha, People’s Republic of China
| | - Bo Yang
- The First Affiliated Hospital, Department of Pharmacy, Hengyang Medical School, University of South China, Hengyang, People’s Republic of China
| | - Wei Li
- Department of Nephrology, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Jun Liu
- Department of Nephrology, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Hongyi Tan
- Center for Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Research Center of Drug Clinical Evaluation of Central South University, Changsha, People’s Republic of China
| | - Chengxian Guo
- Center for Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Research Center of Drug Clinical Evaluation of Central South University, Changsha, People’s Republic of China
| | - Hao Zhang
- Department of Nephrology, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Guoping Yang
- Center for Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Research Center of Drug Clinical Evaluation of Central South University, Changsha, People’s Republic of China
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Hashimoto M, Maeda H, Oniki K, Yasui-Furukori N, Watanabe H, Saruwatari J, Kadowaki D. New Insight Concerning Therapeutic Drug Monitoring-The Importance of the Concept of Psychonephrology. Biol Pharm Bull 2022; 45:834-842. [PMID: 35786590 DOI: 10.1248/bpb.b22-00025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Recently, the concept of psychonephrology was developed and has been recognized as a field of study that focuses on nephrology and mental health fields, such as psychiatry and psychosomatic medicine. Indeed, patients with chronic kidney disease frequently suffer from mental problems as the disease stage progresses. Most psychotropic drugs are hepatically metabolized, but some are unmetabolized and eliminated renally. However, renal disease may affect the pharmacokinetics of many psychotropic drugs, as the decreased renal function not only delays the urinary excretion of the drug and its metabolites but also alters various pharmacokinetic factors, such as protein-binding, enterohepatic circulation, and activity of drug-metabolizing enzymes. Therefore, when prescribing drug therapy for patients with both renal disease and mental issues, we should consider reducing the dosage of psychotropic drugs that are eliminated mainly via the kidney and also carefully monitor the blood drug concentrations of other drugs with a high extrarenal clearance, such as those that are largely metabolized in the liver. Furthermore, we should carefully consider the dialyzability of each psychotropic drug, as the dialyzability impacts the drug clearance in patients with end-stage renal failure undergoing dialysis. Therapeutic drug monitoring (TDM) may be a useful tool for adjusting the dosage of psychotropic drugs appropriately in patients with renal disease. We herein review the pharmacokinetic considerations for psychotropic drugs in patients with renal disease as well as those undergoing dialysis and offer new insight concerning TDM in the field of psychonephrology.
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Affiliation(s)
| | - Hitoshi Maeda
- Department of Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kumamoto University
| | - Kentaro Oniki
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University
| | | | - Hiroshi Watanabe
- Department of Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kumamoto University
| | - Junji Saruwatari
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University
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22
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Georgianos PI, Eleftheriadis T, Liakopoulos V. Should We Use Dialyzable β-Blockers in Hemodialysis? Kidney Med 2022; 4:100468. [PMID: 35539429 PMCID: PMC9079235 DOI: 10.1016/j.xkme.2022.100468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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23
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Tippayachai P, Leelakanok N, Methaneethorn J. Significant predictors for topiramate pharmacokinetics: a systematic review of population pharmacokinetic studies. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Patinee Tippayachai
- Department of Pharmacy Practice Faculty of Pharmaceutical Sciences Naresuan University Phitsanulok Thailand
| | - Nattawut Leelakanok
- Department of Clinical Pharmacy Faculty of Pharmaceutical Sciences Burapha University Chonburi Thailand
| | - Janthima Methaneethorn
- Department of Pharmacy Practice Faculty of Pharmaceutical Sciences Naresuan University Phitsanulok Thailand
- Center of Excellence for Environmental Health and Toxicology Naresuan University Phitsanulok Thailand
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24
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Zhang J, Chen D, Li X, Ding M, Xu J, Wang M, Chang B. The association between estimated glomerular filtration rate and prognosis in patients with diabetic foot osteomyelitis. Int Wound J 2022; 19:1650-1657. [PMID: 35080116 PMCID: PMC9615297 DOI: 10.1111/iwj.13765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/16/2022] [Accepted: 01/18/2022] [Indexed: 11/28/2022] Open
Abstract
We aimed to explore the association between estimated glomerular filtration rate (eGFR) and prognosis in patients with diabetic foot osteomyelitis (DFO). Three hundred twenty‐one DFO inpatients were enrolled and classified into four groups according to the eGFRs as follows: normal (≥90), mildly reduced (60‐89), moderately reduced (30‐59) and severely reduced (<30). These patients were followed‐up for 6 months to observe the outcomes, including ulcer healing and amputation. The associations between eGFR and the outcomes were analysed by univariate and multivariate logistic regression models. Compared with patients with normal eGFR, patients with severely reduced eGFR group had higher risk of healing failure (OR = 4.72, 95% CI: 1.44‐15.48), total amputation (OR = 4.50, 95% CI: 1.18‐17.13) and minor amputation (OR = 4.05, 95% CI: (1.04‐15.87). Severely reduced eGFR in patients with DFO was an independent predictor for amputation and healing failure.
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Affiliation(s)
- Jinghang Zhang
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases Chu Hsien‐I Memorial Hospital &Tianjin Institute of Endocrinology, Tianjin Medical University Tianjin China
| | - Dong Chen
- Tianjin University of Traditional Chinese Medicine Tianjin China
| | - Xuemei Li
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases Chu Hsien‐I Memorial Hospital &Tianjin Institute of Endocrinology, Tianjin Medical University Tianjin China
| | - Min Ding
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases Chu Hsien‐I Memorial Hospital &Tianjin Institute of Endocrinology, Tianjin Medical University Tianjin China
| | - Jun Xu
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases Chu Hsien‐I Memorial Hospital &Tianjin Institute of Endocrinology, Tianjin Medical University Tianjin China
| | - Meijun Wang
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases Chu Hsien‐I Memorial Hospital &Tianjin Institute of Endocrinology, Tianjin Medical University Tianjin China
| | - Bai Chang
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases Chu Hsien‐I Memorial Hospital &Tianjin Institute of Endocrinology, Tianjin Medical University Tianjin China
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25
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Drug-Dosing Adjustment in Dogs and Cats with Chronic Kidney Disease. Animals (Basel) 2022; 12:ani12030262. [PMID: 35158584 PMCID: PMC8833495 DOI: 10.3390/ani12030262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/13/2022] [Accepted: 01/18/2022] [Indexed: 11/17/2022] Open
Abstract
Chronic kidney disease is a common kidney disorder in adult and aged dogs and cats; the management of associated complications and comorbidities generally requires a life-long medical treatment to ensure a good quality of life of affected patients. However, indications and the literature on drug dosing in dogs and cats with chronic kidney disease are often lacking. The aim of this review is to revise the current literature on drug dosing in canine and feline patients with renal impairment, with a special focus on the most commonly used medications to manage chronic kidney disease and possible comorbidities.
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Gall E, Lafont A, Varenne O, Dumas F, Cariou A, Picard F. Balancing thrombosis and bleeding after out-of-hospital cardiac arrest related to acute coronary syndrome: A literature review. Arch Cardiovasc Dis 2021; 114:667-679. [PMID: 34565694 DOI: 10.1016/j.acvd.2021.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 12/29/2022]
Abstract
Balance between thrombosis and bleeding is now well recognized in patients treated for acute coronary syndrome, with impact on short- and long-term prognosis, including survival. Recent data suggest that patients who are resuscitated after out-of-hospital cardiac arrest related to myocardial infarction are at an even higher risk of bleeding and thrombosis than those with uncomplicated acute coronary syndrome. Delayed enteral absorption of medication due to induced hypothermia and systemic inflammation increases thrombosis risk, whereas transfemoral access site, cardiopulmonary resuscitation manoeuvres and mechanical circulatory support devices increase bleeding risk. In addition, post-resuscitation syndrome and renal or hepatic impairment are potential risk factors for both bleeding and thrombotic complications. There are currently no randomized controlled trials comparing various P2Y12 inhibitor and/or anticoagulation strategies in the setting of out-of-hospital cardiac arrest, and current practice is largely derived from management of patients with uncomplicated acute coronary syndrome. The aim of this review is therefore to describe the bleeding and thrombosis risk factors in this specific population, and to review recent data on antithrombotic drugs in this patient subset.
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Affiliation(s)
- Emmanuel Gall
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Alexandre Lafont
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France
| | - Olivier Varenne
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France
| | - Florence Dumas
- Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France; Emergency Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Alain Cariou
- Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France; Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Fabien Picard
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France.
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Alruqayb WS, Price MJ, Paudyal V, Cox AR. Drug-Related Problems in Hospitalised Patients with Chronic Kidney Disease: A Systematic Review. Drug Saf 2021; 44:1041-1058. [PMID: 34510389 DOI: 10.1007/s40264-021-01099-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Globally, chronic kidney disease (CKD) is one of the leading causes of mortality. Impaired renal function makes CKD patients vulnerable to drug-related problems (DRPs). AIM The aim of this systematic review was to investigate the prevalence and nature of DRPs among hospital in-patients with CKD. METHODS A systematic review of the literature was conducted using Medline, EMBASE, PsycINFO, Web of Science (Core Collection), CINAHL plus (EBSCO), Cochrane Library (Wiley), Scopus (ELSEVIER) and PubMed (U.S.NLM) from index inception to January 2020. Studies investigating DRPs in hospitalised CKD patients published in the English language were included. Two independent reviewers extracted the data and undertook quality assessment using the Joanna Briggs Institute (JBI) tool. RESULTS A total of 2895 unique titles were identified; with 20 meeting the inclusion criteria. DRPs prevalence in CKD was reported between 12 and 87%. The most common DRPs included ineffective treatment, inappropriate drug choice and dosing problems. Antibiotics, H2-antihistamines and oral antidiabetics (metformin) were common drug classes involved in DRPs. Factors associated with DRPs included severity of CKD, the number of medications taken, age, length of hospital stay, and gender. CONCLUSION This systematic review provides evidence that DRPs are a frequent occurrence and burden for hospitalised patients with stage 1-4 CKD. Heterogeneity in study design, case detection and definitions are common, and future studies should use clearer definitions and study designs. Protocol Registration: PROSPERO: CRD42018096364.
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Affiliation(s)
- Wadia S Alruqayb
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
- College of Pharmacy, Taif University, Taif, Kingdom of Saudi Arabia
| | - Malcolm J Price
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Vibhu Paudyal
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Anthony R Cox
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
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Franchetti Y, Nolin TD. Application of Individualized PBPK Modeling of Rate Data to Evaluate the Effect of Hemodialysis on Nonrenal Clearance Pathways. J Clin Pharmacol 2021; 61:769-781. [PMID: 33459400 DOI: 10.1002/jcph.1818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 01/11/2021] [Indexed: 11/06/2022]
Abstract
The aim of this study was to apply individualized, physiologically based pharmacokinetic modeling of 14 CO2 production rates (iPBPK-R) measured by the erythromycin breath test to characterize the effect of hemodialysis on the function of nonrenal clearance pathways in patients with end-stage renal disease. Twelve patients previously received 14 C-erythromycin intravenously pre- and post-hemodialysis. Serial breath samples were collected after each dose over 2 hours. Eight PBPK parameters were co-estimated across periods, whereas activity of cytochrome P450 (CYP) 3A4 clearance was independently estimated for each period. Inhibition coefficients for organic anion transporting polypeptide (OATP), P-glycoprotein, and multidrug resistance-associated protein 2 activities were also estimated. Nonrenal clearance parameter estimates were explored regarding sex differences and correlations with uremic toxins and were used in hierarchical cluster analysis (HCA). Relationships between the function of nonrenal clearance pathways and uremic toxin concentrations were explored. Mean CYP 3A4 clearance increased by 2.2% post-hemodialysis. Uptake transporter activity was highly intervariable across hemodialysis. Females had 22% and 30% higher median CYP3A4 activity than males pre- and post-hemodialysis, respectively. Exploratory HCA indicated that using both CYP3A4 and OATP activity parameters at pre- and post-hemodialysis best identifies heterogeneous patients. This is the first study to use the iPBPK-R approach to simultaneously estimate multiple in vivo nonrenal elimination pathways in individual patients with kidney disease and to assess the effect of hemodialysis.
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Affiliation(s)
- Yoko Franchetti
- Department of Pharmaceutical Sciences, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
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Landersdorfer CB, Nation RL. Key Challenges in Providing Effective Antibiotic Therapy for Critically Ill Patients with Bacterial Sepsis and Septic Shock. Clin Pharmacol Ther 2021; 109:892-904. [PMID: 33570163 DOI: 10.1002/cpt.2203] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/05/2021] [Indexed: 12/16/2022]
Abstract
Early initiation of effective antibiotic therapy is vitally important for saving the lives of critically ill patients with sepsis or septic shock. The susceptibility of the infecting pathogen and the ability of the selected dosage regimen to safely achieve the required antibiotic exposure need to be carefully considered to achieve a high probability of a successful outcome. Critically ill patients commonly experience substantial pathophysiological changes that impact the functions of various organs, including the kidneys. Many antibiotics are predominantly renally eliminated and thus renal function is a major determinant of the regimen needed to achieve the required antibiotic exposure. However, currently, there is a paucity of guidelines to inform antibiotic dosing in critically ill patients, including those with sepsis or septic shock. This paper briefly reviews methods that are commonly used in critically ill patients to provide a measure of renal function, and approaches that describe the relationship between the exposure to an antibiotic and its antibacterial effects. Two common conditions that very substantially complicate the use of antibiotics in critically ill patients with sepsis, unstable renal function, and augmented renal clearance, are considered in detail and their potential therapeutic implications are explored. Suggestions are provided on how treatment of bacterial infections in critically ill patients with sepsis might be improved. Of high potential are model-informed approaches that aim to individualize initial treatment regimens based on patient and bacterial characteristics, with refinement of regimens during treatment in response to monitoring antibiotic concentrations, responsive measures of renal function, and other important clinical data.
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Affiliation(s)
- Cornelia B Landersdorfer
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Roger L Nation
- Drug Delivery, Disposition, and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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Impact of Adverse Drug Reactions in Patients with End Stage Renal Disease in Greece. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17239101. [PMID: 33291233 PMCID: PMC7730015 DOI: 10.3390/ijerph17239101] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/24/2020] [Accepted: 12/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) require specialized therapeutic interventions. The decreased renal function that modulates the physiology and presence of comorbidities is often associated with variations in the pharmacological response, thus increasing the risk of adverse drug events or reactions (ADE/ADRs) from co-administered drugs. METHODS A cross-sectional study to record comorbidities, drug-drug interactions (DDIs), ADE/ADRs in patients with chronic kidney disease of stage five in Greece. The study enrolled 60 patients of mean age 64.8 ± 12.9 years, undergoing hemodialysis three times a week. Demographic and social factors, comorbidities, laboratory test data, medication regimens, DDIs and the reporting of ADE/ADRs were analyzed. RESULTS Cardiovascular diseases and diabetes were the main comorbidities. In total, 50 different DDIs of various clinical significance were identified. CNS, GI-track, and musculoskeletal-system-related ADE/ADRs were most often reported by patients. ADE/ADRs as clinical outcome from DDIs were associated in 64% of the total identified DDIs. There was a positive trend between number of medications, ADE/ADRs report and DDIs. CONCLUSIONS The impact of ADE/ADRs in ESRD patients should be always considered. Guidelines as well as continuous training in the context of evidence-based clinical practice by healthcare personnel on therapy administration and prevention of adverse events are important.
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Déri MT, Kiss ÁF, Tóth K, Paulik J, Sárváry E, Kóbori L, Monostory K. End-stage renal disease reduces the expression of drug-metabolizing cytochrome P450s. Pharmacol Rep 2020; 72:1695-1705. [PMID: 32638224 PMCID: PMC7704481 DOI: 10.1007/s43440-020-00127-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND End-stage renal disease is an irreversible status of kidney dysfunction that reduces both renal and non-renal drug clearance. Accumulation of uremic toxins seems to modify the activities of drug-metabolizing cytochrome P450 (CYP) enzymes. The aim of the present work was to refine gene expression analysis for efficient and accurate quantification of CYP mRNAs in patients' leukocytes. METHODS We compared six liquid-liquid extraction reagents for RNA isolation and five reverse transcriptase kits for RNA-to-cDNA conversion, and developed quantitative polymerase chain reaction methods for duplex measurements of CYP target genes and the reference gene. The expression of CYP1A2, CYP2C9, CYP2C19 and CYP3A4 in patients with end-stage kidney disease (N = 105) and in organ donors with healthy kidney function (N = 110) was compared. RESULTS Regarding the RNA yield and purity, TRIzol, Trizolate and TRI reagents were equal; however, TRI reagent was the most advantageous in terms of financial cost. Reverse transcription using Maxima First Strand cDNA Synthesis kit appeared to be the most efficient with the widest range for quantification of the target transcript. The refined method with the detection of various CYPs and the reference gene in duplex PCR efficiently quantified even the low-level CYP expression. In leukocytes of patients with end-stage renal disease, all four CYPs were expressed at significantly lower level than in organ donors with normal kidney function (p < 0.0001). CONCLUSIONS Reduced CYP expression was a direct evidence of transcriptional down-regulation of CYP genes in patients with impaired kidney function.
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Affiliation(s)
- Máté Tamás Déri
- Institute of Enzymology, Research Centre for Natural Sciences, Magyar tudósok 2, 1117, Budapest, Hungary
| | - Ádám Ferenc Kiss
- Institute of Enzymology, Research Centre for Natural Sciences, Magyar tudósok 2, 1117, Budapest, Hungary
| | - Katalin Tóth
- Institute of Enzymology, Research Centre for Natural Sciences, Magyar tudósok 2, 1117, Budapest, Hungary
| | - József Paulik
- Nucleotest Bio Ltd., Tündérliget 3/2, 1038, Budapest, Hungary
| | - Enikő Sárváry
- Department of Transplantation and Surgery, Semmelweis University, Baross 23, 1082, Budapest, Hungary
| | - László Kóbori
- Department of Transplantation and Surgery, Semmelweis University, Baross 23, 1082, Budapest, Hungary
| | - Katalin Monostory
- Institute of Enzymology, Research Centre for Natural Sciences, Magyar tudósok 2, 1117, Budapest, Hungary.
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Märtson AG, Burch G, Ghimire S, Alffenaar JWC, Peloquin CA. Therapeutic drug monitoring in patients with tuberculosis and concurrent medical problems. Expert Opin Drug Metab Toxicol 2020; 17:23-39. [PMID: 33040625 DOI: 10.1080/17425255.2021.1836158] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Therapeutic drug monitoring (TDM) has been recommended for treatment optimization in tuberculosis (TB) but is only is used in certain countries e.g. USA, Germany, the Netherlands, Sweden and Tanzania. Recently, new drugs have emerged and PK studies in TB are continuing, which contributes further evidence for TDM in TB. The aim of this review is to provide an update on drugs used in TB, treatment strategies for these drugs, and TDM to support broader implementation. AREAS COVERED This review describes the different drug classes used for TB, multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB), along with their pharmacokinetics, dosing strategies, TDM and sampling strategies. Moreover, the review discusses TDM for patient TB and renal or liver impairment, patients co-infected with HIV or hepatitis, and special patient populations - children and pregnant women. EXPERT OPINION TB treatment has a long history of using 'one size fits all.' This has contributed to treatment failures, treatment relapses, and the selection of drug-resistant isolates. While challenging in resource-limited circumstances, TDM offers the clinician the opportunity to individualize and optimize treatment early in treatment. This approach may help to refine treatment and thereby reduce adverse effects and poor treatment outcomes. Funding, training, and randomized controlled trials are needed to advance the use of TDM for patients with TB.
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Affiliation(s)
- Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen , Groningen, The Netherlands
| | - Gena Burch
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy and Emerging Pathogens Institute, University of Florida , Gainesville, FL, USA
| | - Samiksha Ghimire
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen , Groningen, The Netherlands
| | - Jan-Willem C Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen , Groningen, The Netherlands.,Department of Pharmacy, Westmead Hospital , Sydney, Australia.,Sydney Pharmacy School, The University of Sydney , Sydney, New South Wales, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney , Sydney, Australia
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy and Emerging Pathogens Institute, University of Florida , Gainesville, FL, USA
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Perazella MA, Nolin TD. Adverse Drug Effects in Patients with CKD: Primum Non Nocere. Clin J Am Soc Nephrol 2020; 15:1075-1077. [PMID: 32611663 PMCID: PMC7409750 DOI: 10.2215/cjn.08890620] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Mark A Perazella
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut .,Department of Medicine, Veterans Affairs Medical Center, West Haven, Connecticut
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences and Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, Pennsylvania
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Schijvens AM, de Wildt SN, Schreuder MF. Pharmacokinetics in children with chronic kidney disease. Pediatr Nephrol 2020; 35:1153-1172. [PMID: 31375913 PMCID: PMC7248054 DOI: 10.1007/s00467-019-04304-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/26/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022]
Abstract
In children, the main causes of chronic kidney disease (CKD) are congenital diseases and glomerular disorders. CKD is associated with multiple physiological changes and may therefore influence various pharmacokinetic (PK) parameters. A well-known consequence of CKD on pharmacokinetics is a reduction in renal clearance due to a decrease in the glomerular filtration rate. The impact of renal impairment on pharmacokinetics is, however, not limited to a decreased elimination of drugs excreted by the kidney. In fact, renal dysfunction may lead to modifications in absorption, distribution, transport, and metabolism as well. Currently, insufficient evidence is available to guide dosing decisions on many commonly used drugs. Moreover, the impact of maturation on drug disposition and action should be taken into account when selecting and dosing drugs in the pediatric population. Clinicians should take PK changes into consideration when selecting and dosing drugs in pediatric CKD patients in order to avoid toxicity and increase efficiency of drugs in this population. The aim of this review is to summarize known PK changes in relation to CKD and to extrapolate available knowledge to the pediatric CKD population to provide guidance for clinical practice.
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Affiliation(s)
- Anne M Schijvens
- Radboud Institute for Molecular Life Sciences, Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children's Hospital, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Michiel F Schreuder
- Radboud Institute for Molecular Life Sciences, Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children's Hospital, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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Caruso P, Longo M, Gicchino M, Scappaticcio L, Caputo M, Maiorino MI, Bellastella G, Esposito K. Long-term diabetic complications as predictors of foot ulcers healing failure: A retrospective study in a tertiary-care center. Diabetes Res Clin Pract 2020; 163:108147. [PMID: 32302666 DOI: 10.1016/j.diabres.2020.108147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/31/2020] [Accepted: 04/07/2020] [Indexed: 12/15/2022]
Abstract
AIM The aim of this study was to investigate the factors involved in healing failure in a population of patients with diabetic foot ulcers (DFU) after one year of follow-up. METHODS One hundred and forty-four patients were treated for DFU in a tertiary-care center and had a regular follow-up for one year. Laboratory measurements and clinical assessments, including long-term diabetes complications and risk factors for DFU, were collected at baseline and patients were divided in two groups according to the outcome [Healed group (H, n = 91), and Not Healed group (NH, n = 53)]. RESULTS Compared with H group, NH group had significant higher levels of urinary albumin excretion [H vs NH, median (IQR), 23.5 (10.1, 41.1) vs 26.4 (20.8, 141.1), P = 0.032] and significantly increased prevalence of diabetic kidney disease (DKD) (22% vs 40%, P = 0.038) and Charcot Arthropathy (3% vs 16%, P = 0.025). No differences among the other long-term complications of diabetes, risk factors for DFU or clinical features were found. The multiple logistic regression analysis identified DKD and Charcot Arthropathy as negative predictors of healing. CONCLUSIONS In a population of people with type 2 diabetes with DFU treated in a tertiary-care center, DKD and Charcot Arthropathy were related to poor healing within one year-follow-up.
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Affiliation(s)
- Paola Caruso
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138 Naples, Italy; Unit of Endocrinology and Metabolic Diseases, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138 Naples, Italy.
| | - Miriam Longo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138 Naples, Italy; Unit of Endocrinology and Metabolic Diseases, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138 Naples, Italy.
| | - Maurizio Gicchino
- Unit of Diabetes, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138 Naples, Italy.
| | - Lorenzo Scappaticcio
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138 Naples, Italy; Unit of Endocrinology and Metabolic Diseases, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138 Naples, Italy.
| | - Mariangela Caputo
- Unit of Diabetes, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138 Naples, Italy.
| | - Maria Ida Maiorino
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138 Naples, Italy; Unit of Endocrinology and Metabolic Diseases, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138 Naples, Italy.
| | - Giuseppe Bellastella
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138 Naples, Italy; Unit of Endocrinology and Metabolic Diseases, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138 Naples, Italy.
| | - Katherine Esposito
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138 Naples, Italy; Unit of Diabetes, University of Campania "Luigi Vanvitelli", Piazza Miraglia 2, 80138 Naples, Italy.
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Athavale A, Jamshidi N, Roberts DM. Incomplete responses to the recommended dose of idarucizumab: a systematic review and pharmacokinetic analysis. Clin Toxicol (Phila) 2020; 58:789-800. [DOI: 10.1080/15563650.2020.1743846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Akshay Athavale
- Drug Health Services and Clinical Pharmacology and Toxicology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Nazila Jamshidi
- Drug Health Services and Clinical Pharmacology and Toxicology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Darren M. Roberts
- Department of Clinical Pharmacology and Toxicology, St. Vincent’s Hospital, Sydney, Australia
- Department of Renal Medicine and Transplantation, St. Vincent’s Hospital, Sydney, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
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Pharmacist-led Medication Counseling for Patients Undergoing Hemodialysis: A Path to Better Adherence. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17072399. [PMID: 32244700 PMCID: PMC7177809 DOI: 10.3390/ijerph17072399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/21/2020] [Accepted: 03/23/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The primary objective was to assess the satisfaction of patients undergoing hemodialysis regarding counseling services provided by pharmacists. The secondary objectives were to compare the effect of years on dialysis and the presence of comorbidities on patient satisfaction. METHODS A total of 138 patients were included in the study, and all demographic and clinical variables were retrieved from the dialysis unit records of King Abdulaziz Medical City over a period of 4 months from July to October 2015. Chi-square test and Fisher's exact test were used for group comparisons at a significance level of 0.05. Results: Most patients aged between 51 and 75 years and had been on dialysis for 1 to 5 years; 94.9% of them had comorbidities. The overall satisfaction of patients toward pharmacy services was excellent (77.5%), and approximately 38.4% of patients thought that pharmacists were providing clear information about their prescribed medications. In addition, 55.8 % of the patients did not know that hemodialysis could affect the efficacy of their medications. Conclusions: Patients undergoing hemodialysis were somewhat satisfied with the counseling provided by the pharmacist. Moreover, there is a need for educational programs for patients undergoing hemodialysis that would increase awareness among hospital pharmacists to improve patients' medication knowledge.
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Gorog DA, Price S, Sibbing D, Baumbach A, Capodanno D, Gigante B, Halvorsen S, Huber K, Lettino M, Leonardi S, Morais J, Rubboli A, Siller-Matula JM, Storey RF, Vranckx P, Rocca B. Antithrombotic therapy in patients with acute coronary syndrome complicated by cardiogenic shock or out-of-hospital cardiac arrest: a joint position paper from the European Society of Cardiology (ESC) Working Group on Thrombosis, in association with the Acute Cardiovascular Care Association (ACCA) and European Association of Percutaneous Cardiovascular Interventions (EAPCI). EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:125-140. [PMID: 32049278 DOI: 10.1093/ehjcvp/pvaa009] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/10/2020] [Accepted: 02/04/2020] [Indexed: 12/19/2022]
Abstract
Timely and effective antithrombotic therapy is critical to improving outcome, including survival, in patients with acute coronary syndrome (ACS). Achieving effective platelet inhibition and anticoagulation, with minimal risk, is particularly important in high-risk ACS patients, especially those with cardiogenic shock (CS) or those successfully resuscitated following out-of-hospital cardiac arrest (OHCA), who have a 30-50% risk of death or a recurrent ischaemic event over the subsequent 30 days. There are unique challenges to achieving effective and safe antithrombotic treatment in this cohort of patients that are not encountered in most other ACS patients. This position paper focuses on patients presenting with CS or immediately post-OHCA, of presumed ischaemic aetiology, and examines issues related to thrombosis and bleeding risk. Both the physical and pharmacological impacts of CS, namely impaired drug absorption, metabolism, altered distribution and/or excretion, associated multiorgan failure, co-morbidities and co-administered treatments such as opiates, targeted temperature management, renal replacement therapy and circulatory or left ventricular assist devices, can have major impact on the effectiveness and safety of antithrombotic drugs. Careful attention to the choice of antithrombotic agent(s), route of administration, drug-drug interactions, therapeutic drug monitoring and factors that affect drug efficacy and safety, may reduce the risk of sub- or supra-therapeutic dosing and associated adverse events. This paper provides expert opinion, based on best available evidence, and consensus statements on optimising antithrombotic therapy in these very high-risk patients, in whom minimising the risk of thrombosis and bleeding is critical to improving outcome.
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Affiliation(s)
- Diana A Gorog
- Department of Medicine, National Heart & Lung Institute, Imperial College, London, UK.,Postgraduate Medical School, University of Hertfordshire, Hatfield, UK
| | - Susanna Price
- Department of Medicine, National Heart & Lung Institute, Imperial College, London, UK.,Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Dirk Sibbing
- Ludwig-Maximilians-Universität, München, Medizinische Klinik und Poliklinik I, Campus Großhadern, München, Germany
| | - Andreas Baumbach
- Barts Heart Centre, William Harvey Research Institute, Bartshealth NHS Trust, Queen Mary University of London, West Smithfield, London, UK
| | - Davide Capodanno
- Division of Cardiology, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Bruna Gigante
- Unit of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science, Danderyds Hospital, Danderyd, Sweden
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria.,Sigmund Freud University, Medical School, Vienna, Austria
| | - Maddalena Lettino
- Cardio-Thoracic and Vascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Sergio Leonardi
- Coronary Care Unit, University of Pavia and Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Joao Morais
- Cardiology Division, Leiria Hospital Center, Pousos, Leiria, Portugal.,ciTechCare, Polytechnic of Leiria, Leiria, Portugal
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Diseases - AUSL Romagna, Ospedale S. Maria delle Croci, Ravenna, Italy
| | | | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Hasselt, Belgium
| | - Bianca Rocca
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
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Kächele M, Keller F. [Pharmacokinetics and pharmacodynamics in extracorporeal renal replacement therapy]. Med Klin Intensivmed Notfmed 2020; 116:295-300. [PMID: 32047978 DOI: 10.1007/s00063-020-00654-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 11/18/2019] [Accepted: 11/18/2019] [Indexed: 11/26/2022]
Abstract
Intermittent hemodialysis, continuous hemofiltration and prolonged daily dialysis are used for renal replacement therapy in the intensive care units. Independent of the replacement modality, antibiotic therapy must start with a high loading dose. Dose adjustment to the kidneys must follow 48 h later to prevent toxic accumulation. Dose recommendations on product labels are often underdosed. On continuous hemofiltration, meanwhile many intensivists administer a normal standard dose because the high filtration rate corresponds to a half-normal glomerular filtration rate. After intermittent hemodialysis, a dose similar to the loading dose will be needed. On day off dialysis, the maintenance dose must be adjusted to the failing kidney function. Immediately after prolonged daily dialysis, a loading dose should be given; with twice daily dosing the maintenance dose needs to be adjusted to kidney function. Therapeutic drug monitoring is recommended for gentamicin, vancomycin, piperacillin, meropenem and voriconazole. Due to pharmacodynamic reasons, the target concentration corresponds to the concentration producing the half-maximum effect. Accordingly, the target concentration is the normal peak for concentration-dependent action with bolus dosing. The target is the average steady-state concentration for antibiotics with time-dependent action and continuous infusion.
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Affiliation(s)
- M Kächele
- Zentrum für Innere Medizin, Innere 1, Nephrologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland.
| | - F Keller
- Zentrum für Innere Medizin, Innere 1, Nephrologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
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40
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Abstract
Drugs excreted by the kidney require dose reduction in chronic kidney disease. This adjustment depends on the severity of the disease and what proportion of the drug is eliminated by the kidneys The estimated glomerular filtration rate can generally be used to guide dose adjustment in patients with stable kidney function. However, the formula can be misleading in some patient subsets and other approaches are required At extremes of body mass, the estimated glomerular filtration rate can under- or overestimate kidney function. It may need to be adjusted for body surface area, particularly for drugs with a narrow therapeutic range or requiring a minimum concentration to be effective. Close monitoring of drug effect and toxicity is also needed and can be supported by therapeutic drug monitoring For short courses of drugs with a wide therapeutic index, dose adjustment may not be needed Alternative methods for quantifying kidney function include the Cockcroft-Gault formula (estimates creatinine clearance) or direct measures of glomerular filtration rate using exogenous isotope compounds. These are not commonly required
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Affiliation(s)
- Maurizio Stefani
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney.,St Vincent's Clinical School, University of New South Wales, Sydney.,Department of Renal Medicine, Canberra Hospital and Community Services, Canberra.,Department of Renal Medicine and Transplantation, St Vincent's Hospital, Sydney
| | - Richard F Singer
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney.,St Vincent's Clinical School, University of New South Wales, Sydney.,Department of Renal Medicine, Canberra Hospital and Community Services, Canberra.,Department of Renal Medicine and Transplantation, St Vincent's Hospital, Sydney
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney.,St Vincent's Clinical School, University of New South Wales, Sydney.,Department of Renal Medicine, Canberra Hospital and Community Services, Canberra.,Department of Renal Medicine and Transplantation, St Vincent's Hospital, Sydney
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41
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Thompson-Brazill KA. Pain Control in the Cardiothoracic Surgery Patient. Crit Care Nurs Clin North Am 2019; 31:389-405. [DOI: 10.1016/j.cnc.2019.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fukumura K, Yamada T, Yokota T, Kawasaki A. The Influence of Renal or Hepatic Impairment on the Pharmacokinetics, Safety, and Tolerability of Naldemedine. Clin Pharmacol Drug Dev 2019; 9:162-174. [PMID: 30977959 PMCID: PMC7027783 DOI: 10.1002/cpdd.690] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/19/2019] [Indexed: 12/25/2022]
Abstract
Naldemedine is a peripherally acting μ‐opioid‐receptor antagonist for the treatment of opioid‐induced constipation. Two phase 1 single‐dose studies investigated the pharmacokinetics and safety of a 0.2‐mg oral dose of naldemedine in subjects with renal impairment (mild, n = 9; moderate, n = 9; severe, n = 6; and end‐stage renal disease, n = 8) or hepatic impairment (mild or moderate, n = 8 each) and demographically matched healthy subjects with normal renal and hepatic function (n = 8, both studies). Pharmacokinetic assessments indicate that dose adjustments for naldemedine are not necessary for subjects with any degree of renal impairment or for subjects with mild or moderate hepatic impairment. In subjects with renal impairment compared with healthy subjects with normal renal function, the geometric mean ratios of naldemedine area under the concentration‐time curve (AUC0‐inf) ranged from 82.8% (90%CI 69.5% to 98.6%) to 137.8% (90%CI 114.0% to 166.5%). Renal clearance decreased with reduced renal function (normal function 1.3 L/h; mild impairment 1.1 L/h; moderate impairment 1.0 L/h; severe impairment 0.5 L/h), and only 2.7% of naldemedine was removed by hemodialysis. In subjects with hepatic impairment compared with healthy subjects with normal hepatic function, the geometric mean ratio of AUC0‐inf ranged from 82.8% (90%CI 65.7% to 104.5%) to 105.2% (90%CI 83.4% to 132.6%). Naldemedine was well tolerated in both healthy subjects and subjects with renal or hepatic impairment, and reported adverse events were generally consistent with the known safety profile.
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Abstract
Antimicrobial pharmacology and its effect on prescribing is quite complex. Selecting an antibiotic that will optimally treat an infection while minimizing adverse effects and the development of resistance is only the first step, as one must also consider the patient's individual pharmacokinetic alterations and the pharmacodynamic properties of the drug when prescribing it as well. Patients with CKD may have alterations in their protein binding, volumes of distribution, kidney clearance, and nonrenal clearance that necessitates antibiotic dose adjustments to prevent the development of toxicity. Knowledge of a drug's pharmacodynamics, defined as the relationship between drug exposure and antibacterial efficacy, provides some guidance regarding the optimal way to make dose adjustments. Different pharmacodynamic goals, such as maximizing the time that free (unbound) drug concentrations spend above the minimum inhibitory concentration (MIC) for time dependent drugs (e.g., β-lactams) or maximizing the free peak-to-MIC ratio for concentration-dependent antibiotics (e.g., aminoglycosides), require different adjustment strategies; for instance, decreasing the dose while maintaining normal dosing frequency or giving normal (or even larger) doses less frequently, respectively. Patients receiving hemodialysis have other important prescribing considerations as well. The nephrologist or patient may prefer to receive antibiotics that can be administered intravenously toward the end of a dialysis session. Additionally, newer dialysis technologies and filters can increase drug removal more than originally reported. This review will discuss the place in therapy, mechanism of action, pharmacokinetic, pharmacodynamic, and other pharmacologic considerations encountered when prescribing commonly used antibiotics in patients with chronic kidney disease or ESKD.
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Affiliation(s)
- Rachel F Eyler
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, Connecticut; and .,Department of Pharmacy Services, Yale-New Haven Hospital, New Haven, Connecticut
| | - Kristina Shvets
- Department of Pharmacy Services, Yale-New Haven Hospital, New Haven, Connecticut
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44
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Lea-Henry TN, Carland JE, Stocker SL, Sevastos J, Roberts DM. Clinical Pharmacokinetics in Kidney Disease: Fundamental Principles. Clin J Am Soc Nephrol 2018; 13:1085-1095. [PMID: 29934432 PMCID: PMC6032582 DOI: 10.2215/cjn.00340118] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Kidney disease is an increasingly common comorbidity that alters the pharmacokinetics of many drugs. Prescribing to patients with kidney disease requires knowledge about the drug, the extent of the patient's altered physiology, and pharmacokinetic principles that influence the design of dosing regimens. There are multiple physiologic effects of impaired kidney function, and the extent to which they occur in an individual at any given time can be difficult to define. Although some guidelines are available for dosing in kidney disease, they may be on the basis of limited data or not widely applicable, and therefore, an understanding of pharmacokinetic principles and how to apply them is important to the practicing clinician. Whether kidney disease is acute or chronic, drug clearance decreases, and the volume of distribution may remain the same or increase. Although in CKD, these changes progress relatively slowly, they are dynamic in AKI, and recovery is possible depending on the etiology and treatments. This, and the use of kidney replacement therapies further complicate attempts to quantify drug clearance at the time of prescribing and dosing in AKI. The required change in the dosing regimen can be estimated or even quantitated in certain instances through the application of pharmacokinetic principles to guide rational drug dosing. This offers an opportunity to provide personalized medical care and minimizes adverse drug events from either under- or overdosing. We discuss the principles of pharmacokinetics that are fundamental for the design of an appropriate dosing regimen in this review.
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Affiliation(s)
- Tom N. Lea-Henry
- Nephrology and Transplantation Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
- Department of Renal Medicine, The Canberra Hospital, Woden, Australian Capital Territory, Australia; and
| | - Jane E. Carland
- Departments of Clinical Pharmacology and Toxicology and
- Department of Medicine, St. Vincent’s Clinical School, St. Vincent’s Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Sophie L. Stocker
- Departments of Clinical Pharmacology and Toxicology and
- Department of Medicine, St. Vincent’s Clinical School, St. Vincent’s Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Jacob Sevastos
- Nephrology and Renal Transplantation, St. Vincent’s Hospital, Darlinghurst, New South Wales, Australia
- Department of Medicine, St. Vincent’s Clinical School, St. Vincent’s Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Darren M. Roberts
- Departments of Clinical Pharmacology and Toxicology and
- Department of Renal Medicine, The Canberra Hospital, Woden, Australian Capital Territory, Australia; and
- Medical School, Australian National University, Acton, Australian Capital Territory, Australia
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